Good morning, everyone. I'm Ronna Parekh, and I am delighted to be able to open up this session entitled Meet the Authors, Cultural Psychiatry with Children, Adolescents, and Families. I'm here with my amazing co-editors, colleagues, and friends, Drs. Cheryl Almateen, Dr. Dakota Carter, and Dr. Maho Lizotto, and you'll be meeting them shortly. We want to make this as interactive as possible, so I'll be asking my colleagues to certainly jump in and add their thoughts and their incredible content to each of these slides. We wish we could be there in person, but we will have time at the very end for some questions, and we'll be leaving you with our addresses and our contacts because we really want to hear from all of you. Before I get to the next slide, I would be greatly remiss in not thanking APA Press for giving us this incredible opportunity, and I really want to thank our president, Dr. Vivian Pender, who invited the four of us to present our book under the Meet the Authors section today. There are countless people that we can thank, so I will leave it at that for right now, but I'm sure my colleagues will help me in thanking various other people. Next slide, please. I'm the chair of today's session, but as I mentioned, we're going to make this as interactive as possible, and to the right, there's a copy of our book that came out in January 2021, and APA Publishing is, again, the publisher for our book. Next slide, please. As I mentioned earlier, all four of us are co-editors of this textbook, Cultural Psychiatry with Children, Adolescents, and Families. Doctors Carter and Lozotto have no additional disclosures to report. Dr. Almatina and myself do receive some royalty from Springer Publishing. Next slide, please. Our learning objectives today are four-fold. We'd like to begin by describing the relevance of cultural psychiatry and this APA textbook. We will review in details the five parts of this book, each of which are unique, and then we will end with some questions on how this book can be leveraged every day in our day-to-day work and in our daily careers, and we'll leave you with some blended case examples on how to use this textbook and specifically the five parts in the appendix on thinking about our patients and assessments and treatment of our patients and their families. Next slide, please. We're going to begin with some introductions, and then we'll go through the cultural relevance of cultural psychiatry and children, adolescents, and review some critical definitions before we go into the five parts and the appendix. So let's begin with some introductions, and I will do this in alphabetical order. I'm going to start with you, Dr. Cheryl Almateen, and then we'll do Dr. Carter, and then Dr. Lizotto. Hi, I'm Cheryl Almateen, and I'm a child and adolescent psychiatrist at Virginia Commonwealth University. I am a full professor there, and it is the only job that I've had since I finished fellowship, so I've gotten a chance to work in lots of different areas there. Right now, I serve as interim program director for the Child and Adolescent Psychiatry Fellowship. At the time we started working on this book, I was in the middle of my ELAM fellowship, the Executive Leadership in Adolescent Medicine program that comes out of Drexel University, and I was still at VCU at the time. I'm going to hand off to Dakota Carter. Good morning, I'm Dakota Carter. I'm currently living in Montana. I'm the chair of the Billings Clinic Department of Psychiatry, and in my spare time, I also serve as a medical director for a virtual company called Charlie Health, where we do virtual IOP and provide psychiatric services for those kiddos. I too am a child and adolescent psychiatrist, but not a full professor. When I started on this book, I was still a child fellow. I met these wonderful folks when I was a minority fellow with the APA, and I have to say Cheryl and Ronna and even Maho, even in her youth, has taken me under their wings and taught me so much, and it's been wonderful to be part of this early in my career and also start to mentor other people to do this type of stuff as well, so it's been a wonderful experience. Hi, I am Maria Jose Lizaro, known as Maho, and I am too an early career psychiatrist. I am currently working at Massachusetts General Hospital at the Chelsea Behavioral Health Clinic doing community work with children, adolescent and families, and some adults, and also have a small private practice, and when I started working with my co-authors on this book, I was actually just fresh out of fellowship. It was my first year as an attending. I was working at McLean Hospital, and I think it was obviously an amazing opportunity, and as Dakota said, we've learned so much from Cheryl and Ronna, and it's been kind of a wild ride because of COVID and everything. I think time has kind of taken a different meaning, but it feels like forever ago that we started, and it's been an absolute honor to learn and work with my co-authors. I will now bring it back to Ronna. Thank you so very much. As an important piece of information, all three of my colleagues were recipients of the APA Diversity and or Minority Fellowship Program, which I know very well, because when we started this book, I was at the American Psychiatric Association as one of their deputy medical directors and the seventh director of diversity and health equity, which is amazing for me to even think about, that we in psychiatry have been thinking about diversity and culture for so very long in a formal way, and under my purview were these very incredibly competitive fellowships, and again, I think this just lends to their expertise that they brought to this book. Today, I'm actually the inaugural director of diversity and health equity and inclusion at the American College of Cardiology. So with the next slide, we'd like to just dive in. If I could have the next slide, thank you. We'd like to begin by talking about why cultural psychiatry is important, and I think in order to do that, you need to sort of step back and look at the landscape in the United States. I know my colleagues will agree with me when I make this comment, and I think most child and adolescent psychiatrists have known this for a while. The only kind of child adolescent psychiatry there is in America is cultural psychiatry, and what you're seeing on this slide is the most recent 2020 census data. To the left, you've got the racial demographics, ethnic demographics of children under the age of 18, and on the right, adults 18 and over. If you look at the left pie chart for a second, you see that the majority of people under the age of 18 are from a minority group. Certainly different than the pie chart on the right. To be exact, 52.7% of people under the age of 18 in the United States identify as being from a racial ethnic minority group versus 39.2% of the adults over age 18. In the last 10 years, so since the last census data, there has been an increase by almost 12% of minority kids or kids who identify as being of a minority background, a non-white background, and there's been a decrease in almost 13% of white populations for kids under the age of 18. This is in large part because of the Hispanic population. We have approximately 25.7% of people under the age of 18 who self-describe as being Hispanic versus on the adult side, which is just about 17% who identifies being over, I'm sorry, 17% over the age of 18 that self-describe as being Hispanic. This change in demographics is in large part due to more and more people under the age of 18 describing themselves as being multiracial. You see in the left-hand side in the pie chart that 6.7% of people under the age of 18 self-describe as being multiracial versus 3.3% of adults. This is really just looking at one aspect of one's identity, which is looking at race and ethnicity. If you add in intersectionality, other dimensions of diversity, you're going to have a population of people under the age of 18 as being much more diverse, as well as our adults, but certainly the vanguard of diversity really is in our child and adolescent population. It takes me back to my initial comments. Really, in order to be a competent child and adolescent psychiatrist, mental health provider, you really have to love diversity as much as all of us do and to be able to embrace it. Our book really will help leverage that aspect in you and certainly help you continue to be culturally sensitive and humble in your work. Next slide, please. Our target audience for this book was for all providers of children, including child and adolescent psychiatrists, psychologists, social workers, pediatricians, educators, and hospital administrators. While the populations described are predominantly in the United States, there are overarching cultural themes and mental health concepts which we really believe transcend the United States and are applicable to mental health practitioners around the globe. Next slide, please. I'm going to ask my colleagues now all to certainly add to what I've already said or to add to the next subsequent slides, just to go through some basic logistics. The way this book was organized, we have five major parts, which we'll go into detail. Those five major parts together comprise 22 chapters and three appendixes. It's 450 pages, including the index, but please do not be overwhelmed. You can certainly take one part or one chapter, one appendix, and they are standalones as well. There's four of us co-editors. I think that diversity of background, experience, geographical, you know, diversity really lent itself to making a really incredible volume. It was also a lot more work. You can imagine putting more people on different time zones and different complex lives on regular calls, and I have to say, I think we met almost consistently for over a year and a half. It's always a treat to see them again. We have incredible contributing authors. I mean, I think all of us will say that it was just a treat to have these authors be part of this book, and, you know, we didn't just take the work of the authors and be the final, you know, chapter. We went back, and we had conversations, and I think so many times we were on the receiving end of learning from these international experts, so it was truly a labor of love, and we have an amazing forward, and I'm not going to say much more about it because I'll let my colleague, Dr. Almateen, talk about the forward as this person was an important mentor to her and, I think, an inspiration for all of us co-editors. Dr. Almateen, do you want to add some comments, and then we can pass it on to Drs. Carter and Lizotto? Yes, I absolutely want to add that Dr. Stewart is one of my very first mentors in psychiatry. She helped recruit me into my residency program at what was then Hahnemann University Hospital, and she was chief resident at the time. She was one of the first attendings and supervisors that I had, so I've just been grateful to have been in contact with her for so long and to have benefited from her mentorship. I know that Dakota also considers her a mentor, so I'm going to hand it off to Dakota. I think that is, oh, it's just so wonderful to talk about that. It's generational, right, because I also consider you and Ronna just great people. You reached out, including people, and that's what this book was about. It's about cultural psychiatry inviting everyone to the table, and I think what this book captured was we invited everyone we could to the table. It was so incredible that, and we'll talk about our individual chapters, but the work that we did individually, what we did as a group, as a community, and then going back. We were in the middle of a pandemic. We were editing, adding COVID, trying to talk about how the global pandemic created a lot of chaos. The Black Lives Matter movement really became prominent during the time we were editing this book. The economy was having some issues. There were just so many factors that were influencing cultural psychiatry at that point. So when Ronna calls this a labor of love, it was absolutely a love to work with these incredible women, but it was also so cool to work with other authors, work with people I respect while the world was really changing, even on a cultural level. So it was just, yeah, a labor of love is a perfect term for it. Wow. Yeah, I just wanted to add to that and say that one of the best things I think about this book is, like Dakota was saying, the ability that we had to connect with different people from different backgrounds, different geographical locations, different levels of training as well, and learn from all of them. And as he was saying, we were working on this book in the midst of everything happening in the world, not just COVID, not just Black Lives Matter, but also politically things were changing. So I think it was a very humbling learning experience for all of us because as we were finishing the book, we were realizing there was a big piece missing if we weren't going to add some portion around COVID, this endemic, and how that affected all of us and our patients, because that had huge implications for every child in the United States and above. So I think that the last portion of our book was, if you will, a little bit more challenging because of everything going on in the world, but at the same time, I think it added a different type of depth to the book that we wouldn't have had otherwise. And all of the authors were really incredible in the sense that we reached out and we said we needed to add these portions, we think this is important. And everyone immediately said, of course, and everyone worked really hard to add portions to the book so that we could make it as updated as possible, and to kind of talk about how that affected our patients and how we could understand that better and help them as well as clinicians. So it's been a wonderful opportunity. Thank you so much, Dr. Lozado. And the next slide, as the next slide is advancing, I do want to also give a shout out to APA Press because they were so interactive with us. As Drs. Carter and Lozado mentioned, there was so much happening in the backdrop, and we wanted to go back and actually incorporate some of the distress that was happening, the syndemic issues that came up for our various sections in the chapter, and we were able to actually make some adjustments. And so I think that their interactive process with APA Press was really important and critical to the success of this book. So what part of our business proposal, and for those who have embarked upon this may understand that this is an incredibly important aspect to the book, is looking at other texts on cultural psychiatry and how this proposal for a book might be synchronous with what's already out there. And, you know, it was really important for us as a group of co-editors to do the diligent work. In some ways I was amazed how much was out there, but then I was also struck by how few standalone volumes there were. I have always been a fan of Dr. Russell Lim and his book on the Clinical Manual of Cultural Psychiatry. It was in its second edition in 2015. It was always my go-to book in the adult psychiatry world that I was also practicing in, and I always thought, gosh, it would be great to have a book like that that focused on children and adolescents and transitional age youth and families. And so in some ways we put the Russell Lim book as one example of what was out there. I also, during my child fellowship, we used the McColdrick book quite a bit, which is the Ethnicity and Family Therapy book, and I was blessed to be able to work with Drs. Tristan Garindo and David Rubin at the Massachusetts General Hospital where we put together a book on cultural sensitivity in child and adolescent mental health. And so I will ask each of my colleagues to comment on some of these other texts, and again these are not the only ones, but these were the ones that we submitted as part of our proposal to give sort of a backdrop of the other volumes and important work that was out there that our book would be hopefully a part of. Dr. Almateen, would you like to comment? Yes, just to echo what you said about the limb book when I first read it my first thought was this is amazing and we need one for children and so wanted to work on that book one day and grateful that I had the opportunity to do so. The McGoldrick book came out when I was a resident and I've consistently used it as a resident as a reference and referred others to read it as well saying this is the first place for us to start when we're meeting people that are different from ourselves to try and get some sense of it but the intersectionality came along which we were able to begin to talk about. I had the opportunity to work with the cultural the child psychiatry clinics issue that's mentioned here from October 2010 and then some of our authors were also working in that one as well as working on the global mental health chapter the global mental health issue. Hand checking with Dakota and Maho. I would just add that the cultural formulation through APA Press was also really pivotal for me and I think it also as we'll talk about became a big part of our our book of how to utilize that with the child adolescent population. Yeah and I just want to add kind of I think as a clinician and just fresh out of fellowship I was very thankful for this opportunity because I did feel similarly to what I was saying that Lynn book was outstanding but at times I kind of wished we had something like that for the working child so I thought it was a great in a way complimentation to what's out there already. Thank you so much and we'll have the next slide. You know I was noticing Dr. Almateen as both Drs. Carter and Lozada were talking about you know from our time in training to their time in training there was almost a huge gap it wasn't really an increase in numbers of volumes or material and of course we're going to end today with all kinds of books on cultural sensitivity or they touch upon cultural sensitivity so it's great to see the energy around culture, diversity, equity you know inclusion in terms of our actual academic work. So I'm going to talk a little bit about now the textbooks contents format and approach and really ask my colleagues to lean in here. You know I think Dr. Carter mentioned this and it's so true I think one of the pearls of this book is that it really leverages the cultural formulation and helps people understand how that can be used in this population of children and transitional age youth and adolescents and families. It's in many ways geared toward the practitioner but I think that those of us even in academia who do a lot of writing I've since heard from people who do even research that this book has been very very helpful to them. We begin this book with some basic introductory concepts because we wanted to level playing field in fact after this next couple slides set of slides we'll go through some critical definitions we thought that was really important not everyone's going to agree with those definitions but it starts with all with a level playing field. We introduce some basic skills and attitudes related to the practice of culturally competent and helpful care. We give an overview of the major racial and ethnic groups in section 2. We also talk about cultural concepts that impact individuals across racial and ethnic groups such as spirituality, sexual orientation, and gender identity. We also address external influences such as social determinants of health, immigration status, and the impact of media and children. Again you know I think my co-editors have already talked about this endemic that was happening in the backdrop so talk about social determinants of health impacting you know our our patient population it was certainly impacting all of this and it was happening in real time. And ultimately we were trying to enhance the readers understanding of the clinical applications implications of all chapters including the impact of culture on specific interventions and the culture of technology itself. Dr. Elmatine would you like to add anything to that? Yes so one thing that I would add is that I have been a clinician educator since the beginning so I wanted a book that I could use in my teaching so I could say all right here's read these two chapters and then that would be a good thing so and so I've done that in many different kinds of settings with various combinations of two chapters for the audience. And Ronna I would just add just how robust we approached editing this book is first we sought experts to help write the chapters and then each one of us kind of took the lead on a chapter but we rotated through each chapter so we have incredible authors we've got all of us that have put our lens on it and it's been really incredible for that process to maneuver its way through and the things that we've caught the intersectionality that we could add from our own life experience or patient experiences that we've had I think really really made this a robust textbook for teaching. And just one last thing when we talk about teaching I think it was wonderful that we were asked or suggested to include some clinical pearls and some self-assessment questions because I think that sometimes we're all busy and we don't have time to read the whole chapter so if something were to come up that a clinician would need something kind of pretty on the spot and they can always go to the clinical pearls and just get the big parts of the chapter if they have kind of a question right away and I think the self-assessment questions are always helpful in terms of not just learning but also getting some credits as we evolve in our career and we need to mean things like that. So I thought that was a great addition as well. Thank you all. You know just to piggyback a little bit on what Dr. Lozada said absolutely the clinical pearls that was a suggestion by APA Press which was great. We also had a lot of tables and so for a quick glance somebody who was trying to leverage this book look at the tables and it's incredibly helpful so we tried to make this as user-friendly as possible especially for the busy clinician and I will also you know highlight Dr. Carter's comment that we all reviewed all the chapters and certainly you know we had to lead editors but it was really kind of a treat to be able to say at the end of this we had all looked at all the chapters and that allowed us to make threads throughout the chapters I think which is incredibly important even though you could read them as standalone chapters there certainly was a thread across all of them and all of them had pearls. You're going to see at the end of this presentation some of the blended cases that we used and you'll get a chance to hear from my colleagues here how chapters can be leveraged to help you better understand your patients and even better understand treatment options. Next slide please. There were some challenges as I think my colleagues have already mentioned but I think by far there were so many more opportunities. You know I knew from the get-go that I really wanted to work with these three colleagues. I had admired Dr. Cheryl Elmatine for a very long time. I sat on her committee which she chaired the D&I committee at ACAP. I heard wonderful things about her and I heard that she was a delight to work with and that of course it's very true and I was beyond impressed by both Drs. Lizotto and Carter and their humility of constantly mentioning that they were junior but you know way beyond their developmental years and that in terms of the complexity that they bring to every patient they think about so many different angles you know sort of a testament to this new generation that just thinks with an intersectionality lens. Dr. Lizotto and I had actually just completed a piece of manuscript on Hispanic and Latinx child and adolescents and I just thought wow I can't believe she's a fellow and then of course Dakota Carter had me laughing all the time. He was a member of the minority fellowship program and just again another star that everybody talked about. So there were I knew I wanted to work with three of them. I knew they would just add to it. I was also kind of daunted by the fact that there were four co-editors and you know I had heard from APA Press you know that's going to be more challenging but in a true diversity sense I think it just added so much. I mentioned the logistics of having people on different coasts and different busy lives but I think we all made this book a priority in so many different ways and sort of brought our A game to our meetings and certainly our A game to this volume. So it was a very comprehensive volume. I think it's something that we all really wanted to see something filled with diversity. We brought authors from across the country together disciplines. You know all of us realize medicine is a team sport and none of us see a psychiatrist as being higher up than psychologists or social workers. We really wanted the entire team represented and on an equal footing as well. You know our chapters included overviews, clinical vignettes, clinical pearls, self-assessment questions, tables that were incredibly valuable and have a leverage of clinical formulation interview. I'm going to stop with that because there's more here but I will allow my colleagues to certainly add to that. Dr. Almateen. I think it's fair to say that we have a mutual admiration society amongst the editors. I remember sitting in meetings with you thinking wow it would be great to work with each other and in another kind of project in a project and when I I think we both asked each other at the same day we were both thinking the same thing that day so that that was pretty good. I'm gonna pass it on to Dakota. I think it was Tuesday nights that we met. It was my Tuesday night date with you guys and it was every week and it was something that after it was gone I didn't realize how incredible it was. I think you guys were my COVID buddies. I think that we had happy hours before it was happy and having to do that permanently. I don't it was just an incredible process to to work with authors from so many different diverse backgrounds and then they come back and look at it through various lenses, multiple discussions with each other and I learned a lot from these ladies. They're incredible physicians and mentors and Ronna talks about mentorship and sponsorship. I don't know she's ever known how much that's touched me about how she's influenced my life as well. Cheryl as well and so it's just been it's been incredible to see us work together, become friends, family, just becoming that community of support. I've reached out to Cheryl after I've had some you know a patient commit suicide. There's been some really incredible just bonds that have come from this book and I reach out to some of my co-authors to this day. So it's just been cool how the book was a labor of love as we've stated but it also created just a lot of love in general, friends, community that's been wonderful. Yeah I would add to all of that and I remember when Ronna called me the first time she told me about this book. I was actually at the Latino Mental Medical Student Association meeting in Miami and it was around April of 2018 so I was just about to finish fellowship and I remember feeling like are you sure this is a call for me? I was just so honored because I had always admired her so much through APA and the fellowship, the SAMHSA fellowship, that I couldn't believe that just more early career psychiatrists like Dakota and me were going to be involved. That's a huge opportunity and I think it speaks to Cheryl's and Ronna's kind of I guess view of how training should be. That it's not just about having senior people and more experienced, it's about kind of mentoring and just forming the new generations and I think that's been as I said a huge honor. I didn't know Cheryl and I didn't know Dakota but I feel like I've known them for years and it's not just about the book. I think as they've said we've learned from each other just in terms of clinical work, in terms of just life experience and of course throughout the work in this book it's been years so a lot has happened for all of us and those goals were a lot of times a lifeline where we would talk about what was going on in our lives or just the stress of witnessing some of the things happening in the world and we were in the midst of George Floyd, everything happening and I think we had a space that we could talk about those things that was very I think supportive and just forming as well and that would help us I think be better clinicians and better educators because from having that space we could translate that to our day to day lives. Thank you all and the next slide please. So we're going to start off with some definitions that we feel are really critical for this textbook and some of these definitions you may know some of them you may slightly disagree with but again we want to start with the level playing field. Dr. Carter I'm going to ask you to take this very first one please. Sure and so defining cultural psychiatry it's a very easy thing to do. I'm joking. It's very challenging. We thought about cultural psychiatry in the lens of how the study and treatment of mental illness of individuals is guided through a view of their cultural identity with integration of race with ethnicity, religion, cultural backgrounds and that fed into the idea of intersectionality. That term was coined in 1989 two years after I was born by Professor Kimberly Crenshaw and that comes from an idea of how our culture does not exist in a vacuum. We think about how inequalities persist within certain categories that we may all fall into which could include gender, race, socioeconomic level or class and how those overlapping interactions can really affect someone's health and can make someone feel very isolated and impact mental health in various ways. The minority stress model is another theoretical framework that we kind of utilized in many of our chapters understanding that societal stressors that could include discrimination, marginalization, stigma led to negative physical and mental health via layered cognitive affective interpersonal and physiological responses. As an openly gay man I first read about the minority stress model and how it affected LGBTQIA individuals physically and in their mental health. But this minority stress model has been utilized in various constructs including race, ethnicity, etc. And so putting this all together we really tried to look at how mental health specifically is impacted by someone's diverse background and the categories that they may fit in and the experiences they have as a member of that cultural population. Thank you Dr. Carter and then next slide is about microaggressions and I really want to thank my colleagues for allowing this to be a major topic for our book. I have you know there's a special meaning for me around this term because Dr. Chester Pierce who first defined and coined this term and first wrote about it in 1969 was my mentor for over 20 years. I met him when I was a first year psychiatry resident at the Massachusetts General Hospital and just over the 20 years just really came to understand how this term came about. He was really struggling to find a way to capture the ongoing stain of racism that African Americans were experiencing post Jim Crow era. These subtle incredibly impactful ways that blacks and African Americans were being slighted in society and he was way ahead of his time in so many different ways and talked about how microaggressions predominantly affected minoritized communities and they were more at risk of having multiple microaggressions every day of their life leading potentially to mental health and physical health consequences. Dr. Daryl Sue Wing took that concept and as did many people and elaborated on it and Dr. Daryl Wing Sue actually extrapolated to include other minoritized groups and also described microaggressions as being not just nonverbal which is what Dr. Pierce thought they were predominantly nonverbal. We know 87% of language is nonverbal but Dr. Wing Sue talked about them also being explicit and could be also about language. He defined them as being unconscious versus conscious. He described micro assault as being explicit, conscious, racial or derogatory actions intended to hurt so they were intentional. He also described microaggressions as being microinsults or microinvalidations and both of these are more unintentional and microinsults were defined as being communications that convey rudeness and insensitivities and demean a person's heritage or identity that microinvalidation or communications that exclude, negate or nullify the psychological thoughts, feelings or experiential reality of a person of color. We have an entire chapter that all of us were co-authors on as well on microaggressions. And with that, I'll take the next slide, and I will hand it off to you, Dr. Lozada. Thank you. So the next couple of definitions are also obviously something that we think is key when understanding this book and patients in general. So assimilation is the process in which a minority group or culture comes to resemble the dominant group and assumes their values, behaviors, and beliefs. Of course, this is not what we would strive for, and that's where the other concept of acculturation comes in. And this is more of a dynamic process, multidimensional, continuous, dynamic process through which an immigrant retains aspects of their native culture while simultaneously adopting the new society's cultures. And since this is a dynamic and kind of continuous process, we say or we know that this with generational, each generation, there will be a greater degree of acculturation. And that's kind of what we would hope for as immigrants adapt to the host culture. On the other side, we can talk about acculturative stress as one of the downsides of this process. And that's defined as perceived stress in relation to the process of adapting to this different community. And in brief, it describes the experience of this internal conflict that results from the adaptation to a new host culture. And this includes the internal cultural value conflict and the external pressures to assimilate and how that interacts and the individual faces that level of stress. This is kind of the culture of stressors affect different underrepresented minority groups in different ways. For example, I'm just going to speak about Latinx culture since I co-authored the chapter on that. We know, for example, that discrimination, parental acculturative stress and peer victimization have been identified as potential contributors to Latinx children's psychosocial maladjustment and may increase the risk of psychopathology. So in Latinx culture, we know those are risk factors. Other cultures have other acculturative stressors that also contribute to the stress. And we see that in terms of symptoms when we treat children and adolescents. I'm going to hand it over now to Dr. Matin. So my slide has just two definitions. The first is one that has a couple of different connotations, but I think the first definition and the most important aspect of it is cultural competence as the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet the social, cultural and linguistic needs. And when we look at it from this more global perspective of cultural competence, I think that that's just what we're all striving for and what the book is after for us to be able to understand all of the different aspects of individuals. Some have chosen a definition that is more limited, saying that we want to know everything there is to know about X culture or Y culture. And I think that we all can come to know that that's not something that's really possible because every culture is constantly changing. Being an African-American in the United States today is different than it was when I was growing up many years ago. So I think that cultures change over time. Cultural humility specifically mentions this fact that we have to each have an interpersonal stance that is open to the other person to be able to recognize all of the different aspects of their culture and specifically the ones that are most important to that person. And so that requires lifelong reflection on our part and critiquing ourselves and recognizing I made a mistake there, I need to grow here, in order to be able to interact most appropriately with people from other cultures so that we can always make sure we're constantly learning about another's culture and that we're also looking at what we're thinking and how we're growing. I'm going to hand it back to Ronna. Thank you all. So now let's go into the five parts of this book. Part one, as I mentioned earlier, is really an overview of the major racial and ethnic groups, and it composes of five chapters. Chapter two being the Black Diaspora, Cultural Psychiatry Perspectives on African-American Children, Adolescents, and Their Families. Chapter three, a broad overview of American Indian, Alaska Native, and Native Hawaiian Pacific Islander cultures. Chapter four, the mental health of Asian-American populations. Chapter five, bridging the gap in psychiatric care of Latinx youth and families. And chapter six, the role of culture, stigma, and bias on the mental health of Arab-American youth. And I would say that all of the authors also mentioned intersectionality and multiracial groups as well. I'm going to ask both Drs. Carter and Lozotto to comment. I know each of them led a chapter in this book. Why don't we start with you, Dr. Carter? I know that you were very involved in chapter three, and then Dr. Lozotto, chapter five. Sure. So chapter three, I believe, may be our chapter that has the most authors. It came from a multitude of contributors that were from different geographic locations, but most also identified as a tribal or native person that had something in their family or they identified that as themselves. And so this created a perspective to be as inclusive as possible for a very, very large population that is impacted through cultural psychiatry. I'm very proud of the chapter as I am native myself, and it really identified what the native population goes through. Now working in Montana, very close to reservations, there's a difference between academics and reading about it and then also treating these patients. And to see it firsthand, it's very eye-opening and very, very, it's heart-wrenching, but it also makes our work that much more important, especially as someone who is native, to give back to our communities. And so I'm very proud of the chapter because it was inclusive, it included so many incredible co-authors and really spoke about a major problem that we need to continue to focus on in the United States. Maho? Thank you, Dakota. Yeah, and I had the opportunity to co-author Chapter 5, which is all centered around Latins' mental health. I had the incredible honor to work with Lisa Fortuna, who is now the chair of psychiatry actually at UCSF, and Andres Martin, who's been an editor at Jacob, a professor at Yale, a great educator. And so I just felt like I learned so much from them as we were working on this chapter. And obviously, this is not just a dear chapter to my heart because I'm Latins, but also it's an important chapter because as we said, the majority of the children and adolescents from underrepresented minority backgrounds in the U.S. right now is coming from actually Latins' backgrounds. So it's a huge, in a way, part of who we are as clinicians treating children, adolescents, and families. So I am very happy with how the chapter turned out. And I think it gave, as we mentioned earlier, we had the chance to add some tables and some clinical pearls, which I think give the chapter that part of a quick read that one might need if you're in a pinch with a patient. So now I'm going to bring it back to Rana. Thank you. Dr. Almateen, would you like to make any comments on part one? No, I worked closely with the folks for chapter two, my co-chair in diversity and culture, as well as chapter six, whom I also worked with on diversity and culture committee. Another thing we haven't mentioned is that both of us are very active in, I'm very active in ACAP, you're very active in APA, and so we really brought the resources of both organizations together. This book is a true mix of people who spend their time in different organizations. Yes, I would say that this was an incredible section, and again, huge populations and so much heterogeneity within each chapter, and that was really brought out in these chapters. So incredible section. Can I have the next slide, please? Part two was looking at cultural concepts, and these are concepts that were very much woven into the previous section and in the racial ethnic groups already outlined. Chapter seven looked at gender and sexuality in the 21st century, cultural psychiatry for children, adolescents, and families. Chapter eight was entitled Religion and Spirituality in Child and Adolescent Cultural Psychiatry, and chapter nine, you cannot have a book on children and adolescents without including families. Any comments? I will start with Dr. Zalmatin, and then Dakota and Carter, I mean, and Lizoto, please. For me, just more folks from diversity and culture, I neglected to say Annie Lee for the Asian chapter was also one of the folks that I tried to help recruit for this. And the symmetry for religion and spirituality is that the first person who ever invited me to write a chapter is the lead person for this chapter, so that's mine. I just want to continue to highlight the intersectionality that each one of these chapters highlights. I know specifically in chapter seven, I was a co-author on that chapter, and while we did a general overview of gender, sexuality, transitioning youth, non-binary youth, the ending of the chapter was very focused on how things like religion, geographic location, race and ethnicity, et cetera, can also impact someone's experiences in LGBTQIA youth. And so intersectionality rings true throughout these chapters, and specifically in the chapter I co-authored. I know it's a huge topic of what it's like to have that onion, the multilayers of being a human with a cultural background. Yeah, and I just want to add that I personally found the chapter on religion and spirituality to be actually a huge addition, because I hadn't really seen that in other textbooks. So I found that very helpful. Obviously chapter seven is a must nowadays, and chapter nine as well, as a clinician working with children and families. So I think the second part of the book is actually something that is pretty neat, because I hadn't seen something like chapter eight included in other places. Thank you so much, and I will echo that these concepts can be found in the chapters in part one, and we thought they were important enough to have a standalone part so we could go into more detail. The next slide looks at part three of our book, and this includes several chapters. Chapter 10, The Social Determinants of Child and Adolescent Mental Health, led by the incredible Dr. Sarah Vinson at Morehouse School of Medicine. We had chapter 11 on aliens, illegals, deportees, children, migration, and mental health. Can I just say this topic seems to ring through constantly when we think about what's going on in the world and the great migration of so many people, including children and adolescents, and the effect that that will have on their mental health for generations to come. Chapter 12 was entitled Clinical Strategies to Address the Mental Health of Forcibly Displaced Children, Refugees, Asylum Seekers, and Unaccompanied Minors, the Role of Silence, Family, and Socioecological Resilience. Chapter 13 was The Global State of Child and Adolescent Mental Health. Chapter 14, Digital Media, Culture, and Child and Adolescent Mental Health. Chapter 15, Culture of Technology, Use of Telepsychiatry, and Other Advances to Engage Children, Adolescents, and Transitional Age Youth. And Chapter 16, Rural Psychiatry. You know, I cannot believe we had such diversity of chapters in this section. I mean, talk about incredible contributions from these diverse authors, and many of whom are experts. You know, Dr. Susan Song is a consultant for the United Nations Refugee Commission, and she took time out to contribute for us. And just, again, so many people who are experts in these areas really pushed all of us to think more broadly and think about the different components of not only our children and adolescents, I think in many ways this book helped me become a better adult psychiatrist as well. I'm going to ask each of my colleagues, starting with Dr. Almateen, to comment on Part 3, which was entitled External Influences. I think this is really, this really talks about intersectionality and leads more into the challenges that were happening in our communities at the time. Dr. Vinson and Dr. Shim were working on their own book at this time, and it came out at about the same time as ours, Social Injustice and Mental Health. I worked closely with the authors on Chapters 10 and 16, and they were really important as we looked at the syndemic and the impact of COVID as well as the social unrest. Handing it off to Dakota and Maho. You know, I think the book clearly just grows on itself. You know, you have the first part talking about race and ethnicity, then we have our general concepts. I personally just learned a lot from Part 3 of the External Influences. As the sole author of Chapter 15, taking that on before a global pandemic hits, when we all become telepsychiatrists, was a major change and was something as a, we keep saying, a labor of love. That chapter changed incredibly once the pandemic hit. And so just, I use that as an example of how culture can change just in a moment and how this book is capturing moments, but it also is growing upon itself. And there's so much that we continue, that cultural humility idea that Cheryl was talking about that we all just have to continue to learn and move as things change. Thank you, Dr. Carter. And I know, Dr. Lozada, you're going to save your comments for the next slide, so thank you. I will ask for the next slide, which is Part 4. Part 4 was looking at developmental stages, family, and clinical implications. You've heard us all talk about how child and adolescent and transitional age youth psychiatry is synonymous with cultural psychiatry. It can also be synonymous with developmental psychiatry. And this part had four chapters, infant psychiatry, culture, and early childhood. It also included adoption and foster care systems. It also had a standalone chapter on microaggressions, early effects in early life, and strategies to overcome. And had an incredible chapter on college mental health. I think for the sake of time, I'm going to go into the next slide, and I'll ask my colleagues to comment at some other later point. I want to leave you maximum amount of time in your sections as well. And finally, Section 5 was about applied concepts. Section 21 was about DSM-5, outline for cultural formulation, and cultural formulation interview, looking at complex case examples. Again, this was interwoven in all of the chapters. It was a thread, but we also wanted a standalone DSM-5, OCF, and CFI. And we finally concluded with, I think, a critical aspect of mental health in general. Believe it or not, when we entered the profession of mental health, we also became advocates for our patients, their families. And it was incredibly important for us to maintain this, if not formally, and certainly in an informal role, putting our patient at the very center, along with their families. With that, I'm going to pass it on to my colleagues. I'll start with you, Dr. Almateen. I know you've got some slides and some cases, and then you'll pass it on to Drs. Carter and Dr. Lizotto. And I will come back at the very end. Thank you very much. Okay. Thank you. So, first, just in looking at this for Chapter 21, and I worked on Chapter 21 with colleagues from VCU, we talked specifically about the cultural formulation interview and the outline for cultural formulation. And this slide has an update on the recommendations for when to use the cultural formulation interview that are in the DSM-5 TR, in the DSM-5 TR, period. One of the things that the DSM-5 TR is doing is more formally recognizing all of these intersectional concepts that we talked about, as well as concepts of social determinants of health, and it's specifically listed in the outline for cultural formulation. So, a couple of things that were added here about when we should be thinking about using the cultural formulation interview, which is a way to get us the information that we need for the outline for cultural formulation, is that we need to consider divergent views of symptoms or expectations of care based on the patient's previous experience with other cultural systems of healing and health care. So specifically asking that question, have you ever felt like things didn't go well somewhere else, so that we can try and correct that now. And that also moves into the potential mistrust of mainstream services at services and institutions by individuals with collective histories of trauma and depression, and that makes a difference. And so listing this in the DSM is helping us all understand more clearly that this is something that we need to consider, as well as the basic reasons why we wanted to think about the CFI, which was if somebody was formally disagreeing with you, or if your usual judgment just wasn't working, maybe there's something else you needed to consider and it was culture. That remains true, but we now need to look at these other systemic issues as well. For the next slide, the way that we use the cultural formulation interview with children and youth is just a little bit different, and so we've listed these things to consider in our text. That it's important to be brief, that we know attention span and concentration increase with age, and we may not get all of the information at once, so we may do this gradually over several different interviews that we have with children and their families. We want to adapt the questions to the patient's cognitive and linguistic development, and we do that with everything else we do, and so we just want to continue to do that. And of course, we need to include collateral information. That's part of what we've mentioned as we're talking about this. And then in Chapter 21, we have four very complex case cultural formulations. The first is an African-American young man who's very much into the anime culture, and it impacts his clinical presentation, and so the lead author actually worked with a couple of patients like this and combined their cases together. The next case is Evangelical Christianity and LGBTQ plus issues, which echoes kind of some of the things that were in the previous chapter. Next is a multiracial patient, and the next is a patient who is Muslim and an immigrant. So just a little bit from that case, he's a 14-year-old refugee who came to the United States two months before his admission after an attempt to stab himself. He attempted to stab himself after he learned that his betrothed had been kidnapped for a ransom. He neither spoke nor understood English. He was only fluent in his native tongue, which was extremely rare and which the video interpreters did not have a person who could interpret. There was only one interpreter in the state and who was about three hours away, and we were able to get her for part of one day, and that was the key, of course. She was able to help us fully understand what was going on with him, and once he did find out that his fiance had been rescued, he was no longer suicidal. It was purely situational, and he felt that this was something he had to do out of a sake of pride for his family. So it was helpful to see what kinds of things larger systems had not thought about to provide for him from a cultural perspective, and we were able to correct for some of those things with the use of an appropriate interpreter. I'm going to pass on to Dakota because I believe we are running low on time. Oh, I'm sorry. We had a couple of appendices. We really wanted this volume to show everything that you need for culture that was in the DSM-5 so that you had a one-stop shop to be able to provide your clinical work or to use it for teaching, and so we had the entire outline for cultural formulation, the cultural formulation interview, and the glossary of cultural concepts of distress in addition to the glossary that we had with definitions that spanned throughout the text. Now to Dakota. So advocacy, it could be its own presentation, and so I'll be as brief as possible, but within cultural psychiatry as a child and adolescent psychiatrist, we've mentioned it before, but as a CAP, you are a cultural psychiatrist. I always say to folks that with only 8,500 practicing child psychiatrists in the U.S., we are all kind of like unicorns, and so even if you're a provider that's not actually a CAP but seen children adolescents, there are so few of us that your engagement with diversity and culture is going to be very important for you to be successful in taking care of your patients. Part of that is also mentorship, sponsorship, if you're a teacher, using your voice, being able to speak up and speak out about these issues and make sure that your patients are being taken care of. And just like we've talked about with this book, it's all hands on deck, and so whether you are a fellow or early child psychiatrist or someone later in their career, every voice matters, every experience matters, and we need to have those people engaged. We have seen a large increase in technology, which has its potential to expand care, but as I note in my chapter 15, there are very significant means to make it equitable, make it just, and make it therapeutic. There are significant issues that touch folks that, like socioeconomic level, access to Wi-Fi, rural versus geographic. Living in Montana, we take that even further with frontier psychiatry and recognizing that some folks may not have access or may be actually driving to go to a telepsychiatry appointment, and so looking at how those issues may be impacting your patient population is very important. As noted, going back to using your voice and technology and how our practice is always changing, regulations and laws are changing. States are changing laws with the pandemic being over. A lot of states are going back to old laws that make no sense anymore, and so they're needing more physicians and providers to speak up about what should continue, what expands care and gets folks seen. There's starting to be a lot of differences between state and federal regulations that we need to advocate for to make sure that it's fair and equitable for our patients, and then the use of resources. APA has multiple resources out there for you to look through. Going through CAGER, that's the Committee on Advocacy and Government Relations through the APA that helps to navigate some of those challenges, but I also think just personally, diversity, equity, inclusion, and belonging in your place of work is also important, and being a change agent for the folks that you work with, being the folks that you know, whether you're teaching, and to be a change agent for your patients. Belonging is a new piece of diversity and equity work, which I really engage with, being that it's the emotional feeling of feeling accepted, and you know, for example, utilizing this in my current career is offering cases to be seen for folks that are seeking employment, to see how they would interact with someone from a diverse background. To be frank, it helps weed out folks that may not be appropriate for your venue, and it also elects in a lot of really quality people who understand how important diversity, equity, inclusion, and belonging actually is in taking care of patients. With that, I'll be very clear, so this slide is always scary. This is what I use to recruit child and adolescent psychiatrists. This map is from ACAP, and what you see is a little bit of yellow in the northeast and a lot of red, and just to break this down very, very clearly, is this is how much of a shortage we have in the United States related to child and adolescent psychiatrists, and so as you can tell, there is no green for a sufficient coverage. High shortage of only having 18 to 46 per 100,000 population is seen in the northeast, but there's only 1 to 17. This map is interactive. When you go to the ACAP website, you can click on each state. You can look on your individual state to see what it's like, but as you can tell, from Pennsylvania, western, we have a severe shortage, and so this goes again, just to not be an echo chamber, but to talk about how important as a child psychiatrist and a provider it is to recognize your role in cultural work and in adversity work, and that you are a cultural psychiatrist when you become a child and adolescent psychiatrist, and just to wrap up with a clinical vignette that captures some of these ideas, we're going to talk about Martin, who's a 14-year-old 8th grader who has a history of ADHD, who was referred for mood dysregulation. He's been getting in trouble at school, becoming aggressive, and there's a note that he may be on the autism spectrum. Martin's living with his maternal grandmother, lives in a small community where people live below the poverty level, and the resources are scarce, and he's got a referral clinic that's contacted out to telepsychiatry. The telepsychiatrist knows there's a connection between Martin and a local nurse that helps kind of facilitate these appointments. They have a good rapport, even though Martin has poor eye contact and some, you know, social issues that prevent him from being super interactive on the telepsychiatry screen. His maternal grandmother acknowledges that Martin needs the help, but they're having trouble understanding how this technology works, especially as she just recently got a smartphone and a Wi-Fi connection. So this touches on so many issues, engaging with diverse youth with a clinical diversity that may present some challenges within telepsychiatry, but also brings in things like socioeconomic level, class, rural versus urban, access to things like a smartphone or Wi-Fi, and how that may impact. Going back to my original slide, is it's one thing to say we offer telepsychiatry, but is that equitable and just for everyone? Does everyone have access to that? And so when you think about issues like this, making sure that just because you've checked some boxes, you have to also continue to think within a cultural lens of how do you make sure you're engaging and able to interact with all your patients? And this is Maho. Thank you, Dakota. Yeah, and I feel like before I even talk about my case, what you've just said about equity and access to telepsychiatry is key, especially nowadays that we're seeing a lot of our patients remotely. In the community clinic I work, that's very much the case. Lots of times it says virtual encounter, and then when you click and you're waiting for the patient and they don't arrive, and then you call them, and the parent is like, I don't have a computer. I have an Obama phone, many of them say. So they barely have, many of them barely have even access to technology. So it's not the same to say we offer telepsychiatry as we are able to really give that to patients. So the case I'm going to present is part of the Chapter 5 on Latinx mental health, page 78. So I'm going to try to summarize it because it is a pretty extensive case. But Andrea is a 12-year-old girl born in New York City. Her family is from El Salvador, and she has two siblings, one that was born in the US with autism spectrum disorder, and the older sister who is, quote, unquote, a dreamer. And this is very obviously common nowadays, where we have a family of mixed status, if you will, with children and parents of different immigration backgrounds living here in the United States. So Andrea is a good student, wants to be a doctor when she grows up. But as the immigration rates become more frequent in her community, and the negative media messages also become more frequent, she becomes increasingly anxious and worries about what will happen to her, her family, especially her siblings, if her parents were to be deported. So she begins having some difficulties with eating and sleeping, difficulties at school with focusing, appears sad, distracted, her grades start to decline. And as many of our patients, the parents worry about her, but they feel uncomfortable communicating with school or even clinicians, because sometimes, as we know, patients that are undocumented worry a lot about their, their status and how they're going to be understood. And if they would be separated from their children, because of that status. Next slide, please. So in this case, we tried to just show how actually the school can be involved in many ways, it doesn't need to be a referral to a child psychiatrist, which as Dakota mentioned, it's not widely available. So the school therapist knew that culturally appropriate care and treatment in Spanish was critical for this family. So she began using narrative therapy, which is a therapy that focuses on helping people to therapeutically express and define their own story. And it's a really great technique, especially with, with immigrant families, because it allows the, the patient to externalize some of those problems and identify how that problem has challenged their core strengths or bond. And it can help families or parents in this case with coping and supporting their children. So this therapist also connected the family with a family navigator or case manager who addressed many of the biggest needs they had, which were related to more just social needs in terms of healthcare, social services and legal resources, which were key. So I think this case in a way exemplifies a lot of what we've been discussing in terms of the challenges that a lot of communities face in terms of immigration status, language, difficulties understanding care and how care is accessed. And then the importance of just trying to get the most of any situation. In this case, the school therapist was actually the key treater. It doesn't always have to be a child psychiatrist. And that's why in a way we wanted to have this book be readily accessible to lots of clinicians, not just a child psychiatrist, because we recognize that that not might not be the case in every clinical encounter. With that, I'm going to bring it back to Rana. Thank you so very much. You know, I think for the sake of time, and you have heard from each of my colleagues, how this textbook is being leveraged in their day to day lives. You know, three of them are active clinicians. And so you can imagine how this book comes in handy all the time for themselves and their colleagues. I want to say Dr. Carter, you commented about being an advocate for diversity, equity, inclusion and belonging. I mean, that's my full time job. And certainly, my work today is the chief diversity, equity inclusion officer at the American College of Cardiology. I have to thank my roots as a child psychiatrist, and being by definition, a developmental psychiatrist and a cultural psychiatrist that really laid the foundation for the work today. You know, the other thing about this book, for those of us who are change agents within our respective organizations, this gives you the science. So many times people think the work that we do is sort of this gray aspect. We now have evidence based materials, this volume, but there's so many other volumes that Dr. Almateen will share with you in the next couple of slides that really give the evidence for why this work is so incredibly important in whatever capacity and way that you want to make the point. Dr. Carter talked about belonging. You know, we all know that in a Maslow's hierarchy of needs, the first and most important point always is a sense of belonging. And I think this book gave people a sense of belonging. But I also think it resonates for so many people and most of all, our patients and our families. It makes them feel like they are part of this field. And it's so important to first and foremost, listen to where our patients are in their families and all the different aspects of them that make them unique and important. With that, I'm going to ask Dr. Almateen to share with us some books that APA Press has out right now that complement and are synchronous around this topic. Dr. Almateen. Hi. Okay. So first is, of course, the LIM book. And all of these pictures are from the AAPI website right now. We have the DSM-5 handbook on the Cultural Formulation Interview. And complementary to ours is Culture, Heritage and Diversity in Older Adult Mental Health Care. And the Shemin Vinson book that we talked about earlier, Social Injustice and Mental Health. And then also just recently thinking about prescribing, which is the psychology of prescribing for diverse children and families has just come out from American Psychiatric Press. And as a set of BIPOC folks who recognize ancestors, this is just a set of the books that have previously been published in the area, spading back to 1996 through 2018. And then also some that are more current. So this is, sorry for the formatting here, but this goes all the way up from 2002 to 2020. And all of these are American Psychiatric Press. So recognizing intersectionality over the decades, I think is a fair way to describe it. Back to you, Ronna. Thank you all very much. Again, I want to thank my incredible colleagues and my friends for life, Drs. Al-Mateen, Carter, Lizotto, and really want to thank APA publishers for having this vision of this book and working all the way along this journey with us. I want to thank again, the scientific committee and the chair, Dr. Catherine Crone for inviting us, Dr. Vivian Pender, the president of APA for inviting us. And last but far from least, the people behind the scenes today and you, Anthony, for being incredible as we navigated this virtual presentation. Thank you again.

Cultural Psychiatry

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Mental Health Professionals

Cultural Competency

Assimilation

Acculturation

Acculturative Stress

Minority Stress Model

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Access to Care